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Objective To investigate the long-term efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of primary biliary cholangitis (PBC) with portal hypertension. Methods A retrospective analysis was performed for 102 patients who received TIPS in Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2015 to August 2021, and these patients were divided into PBC group with 41 patients and viral hepatitis cirrhosis group with 81 patients. Related indicators were collected, including routine blood test results, liver and renal function, coagulation function, portal vein thrombosis, hepatic encephalopathy, and etiology of TIPS treatment shortly after admission, preoperative portal venous pressure, and stents used in surgery, and Child-Pugh score was calculated. Follow-up data were collected and analyzed, including postoperative upper gastrointestinal rebleeding, stent dysfunction, hepatic encephalopathy, and the data on survival and prognosis. The independent samples t -test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of continuous data with skewed distribution between two groups; the chi-square test was used for comparison of categorical data between two groups. The Kaplan-Meier method was used for survival analysis, and the log-rank test was used for survival difference analysis. Results In the PBC group and the viral hepatitis cirrhosis group, the median percentage of reduction in portal venous pressure after surgery was 33.00% and 35.00%, respectively, and there was no significant difference between the two groups ( P > 0.05). At the end of follow-up, there were no significant differences between the PBC group and the viral hepatitis cirrhosis group in stent dysfunction rate (14.63% vs 24.69%, χ 2 =1.642, P > 0.05), upper gastrointestinal rebleeding rate (17.07% vs 24.69%, χ 2 =0.917, P > 0.05), the incidence rate of overt hepatic encephalopathy (12.20% vs 7.41%, χ 2 =0.289, P > 0.05), and disease-specific death rate (14.63% vs 9.88%, χ 2 =0.229, P > 0.05). Conclusion For PBC patients with portal hypertension, TIPS can achieve the same efficacy as the treatment of portal hypertension caused by viral hepatitis cirrhosis and can also effectively reduce portal hypertension without increasing the incidence rate of complications and disease-specific death rate. Therefore, it is a safe and effective treatment method.
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Sarcopenia is a common complication of liver cirrhosis and is significantly associated with poor prognosis. Transjugular intrahepatic portosystemic shunt (TIPS) is an important method for the treatment of portal hypertension and its complications. Based on current studies, this article analyzes the association between sarcopenia and the outcomes (hepatic encephalopathy and mortality) of patients with liver cirrhosis after TIPS and the value of improving the predictive ability of existing prognostic models for sarcopenia, as well as the improvement in sarcopenia after TIPS and its significance in the clinical management of patients with liver cirrhosis. A comprehensive analysis of existing reports show that baseline sarcopenia is associated with poor prognosis after TIPS, and it is thus recommended to evaluate nutritional status before TIPS based on radiological examination; TIPS can improve nutritional status and help to achieve reversal or improvement of sarcopenia to a certain extent, and it can also be translated into survival benefit. Therefore, for patients with sarcopenia and a relatively stable disease, TIPS can be performed as soon as possible after comprehensive evaluation.
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Refractory ascites is one of the common complications of portal hypertension in decompensated liver cirrhosis and is characterized by extremely poor prognosis and high mortality rate. Transjugular intrahepatic portosystemic shunt (TIPS) is recommended by several international and national guidelines as one of the treatment methods after failure of large volume paracentesis combined protein infusion therapy. TIPS can effectively control the recurrence of ascites, but it can increase the risk of hepatic encephalopathy, and there are still controversies over whether it can prolong survival time. With a deeper understanding of TIPS, the maturity of surgical techniques, and the update of stent materials, it is urgent to reevaluate the position of TIPS in the treatment of refractory ascites due to portal hypertension. This article reviews the current status and advances in TIPS for the treatment of refractory ascites due to portal hypertension.
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Esophagogastric variceal bleeding (EGVB) is one of the main complications of decompensated portal hypertension, especially in patients with liver cirrhosis, and it often has a high mortality rate. Medication combined with endoscopy is the main prevention and treatment method for EGVB, while transjugular intrahepatic portosystemic shunt (TIPS) combined with variceal embolization can also be selected for some high-risk patients, and individualized diagnosis and treatment of portal hypertension based on hepatic venous pressure gradient should become the latest consensus and the main strategy. This article mainly reviews endoscopic therapy and TIPS for the prevention and treatment of EGVB patients with decompensated portal hypertension in terms of selection of indications, incidence rate of complications, and respective advantages and disadvantages.
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Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure to establish a portosystemic shunt between the hepatic vein and the portal vein via the jugular approach, so as to reduce portal venous pressure and control acute esophagogastric variceal bleeding (EGVB). The prognosis of EGVB has been improved significantly over the past few decades, and endoscopic variceal ligation combined with drug therapy is now recommended as the first-line treatment regimen for this disease. The latest research advances in the management of EGVB over the past decade have focused on the relatively new concept of "early" or "pre-emptive" TIPS, that is to say, early TIPS (within 72 hours after admission, ideally within 24 hours) is recommended for patients with EGVB who are at a relatively high risk of failure in standard treatment. This article briefly introduces the effect of early TIPS on controlling bleeding, mortality rate, and hepatic encephalopathy, the high-risk population for early TIPS, timing of intervention, cost effectiveness, the applications of early TIPS in a real-world setting, and recommendations for early TIPS in international guidelines and consensus statements.
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Transjugular intrahepatic portosystemic shunt (TIPS) is a safe and effective method for the treatment of portal hypertension complications in patients with decompensated liver cirrhosis. At present, there are many prognostic scoring tools for risk stratification of poor prognosis after TIPS. This article briefly introduces seven prognostic scoring tools commonly used for TIPS and summarizes the clinical research evidence of each scoring tool. The literature review shows that there is currently no sufficient research evidence to determine the optimal prognostic scoring tool after TIPS. Future clinical studies should comprehensively explore the advantages and disadvantages of different scoring tools in predicting short- and long-term adverse prognostic events after TIPS and develop new prognostic scoring tools in combination with new prognostic markers.
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Transjugular intrahepatic portosystemic shunt （TIPS） has been recommended as a treatment method for cirrhotic portal hypertension in domestic and foreign guidelines， but there is still uncertainty in its therapeutic efficacy. More and more studies have shown that TIPS combined with collateral vessel embolization （TIPS+E） has certain advantages in the treatment of gastroesophageal variceal bleeding in liver cirrhosis. This article reviews the major studies on TIPS+E in China and globally， summarizes related recommendations in guidelines and the current status of clinical application， and proposes the issues that need to be solved， such as indication， hemodynamic criteria， and selection of materials for embolization， and large－sample multicenter randomized controlled trials are needed for further clarification.
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Objective To compare the value of Child-Pugh score, Model for End-Stage Liver Disease (MELD) score, MELD combined with serum sodium concentration (MELD-Na) score, CLIF Consortium Acute Decompensation (CLIF-C AD) score, and Freiburg index of post-transjugular intrahepatic portosystemic shunt (TIPS) survival (FIPS) score in predicting the survival of patients undergoing TIPS. Methods A retrospective analysis was performed for the clinical data of 447 patients with liver cirrhosis who underwent TIPS in several hospitals in southwest China, among whom there were 306 patients in the survival group and 62 in the death group. The scores of the above five models were calculated, and a survival analysis was performed based on these models. The independent samples t -test was used for comparison of normally distributed continuous data between groups, and the non-parametric Mann-Whitney U test was used for comparison of non-normally distributed continuous data between groups; the Pearson chi-square test was used for comparison of categorical data between groups; a multivariate Cox regression analysis was used for correction analysis of known influencing factors with statistical significance which were not included in the scoring models; the Kaplan-Meier method was used to evaluate the discriminatory ability of each model in identifying risks in the surgical population, and the log-rank test was used for analysis. The area under the receiver operating characteristic curve (AUC), C-index at different time points, and calibration curve were used to evaluate the predictive ability of each scoring model. Results Compared with the death group, the survival group had significantly lower age ( Z =2.884, P < 0.05), higher albumin ( t =3.577, P < 0.05), and Na + ( Z =-3.756, P < 0.05) and significantly lower proportion of patients with alcoholic cirrhosis ( χ 2 =22.674, P < 0.05), aspartate aminotransferase ( Z =2.141, P < 0.05), prothrombin time ( Z =2.486, P < 0.05), international normalized ratio ( Z =2.429, P < 0.05), total bilirubin ( Z =3.754, P < 0.05), severity of ascites ( χ 2 =14.186, P < 0.05), and scores of the five models (all P < 0.05). Survival analysis showed that all scoring models effectively stratified the prognostic risk of the patients undergoing TIPS. Comparison of the C-index of each scoring model at different time points showed that Child-Pugh score had the strongest ability in predicting postoperative survival, followed by MELD-Na score, MELD score, and CLIF-C AD score, and FIPS score had a relatively poor predictive ability; in addition, the prediction efficiency of each score gradually decreased over time. Child-Pugh score had the largest AUC of 0.832 in predicting 1-year survival rate after surgery, and MELD-Na score had the largest AUC of 0.726 in predicting 3-year survival rate after surgery, but FIPS score had a poor ability in predicting 1- and 3-year survival rates. Conclusion All five scoring models can predict the survival of patients with liver cirrhosis after TIPS and can provide effective stratification of prognostic risk for such patients. Child-Pugh score has a better ability in predicting short-term survival, while MELD-Na score has a better ability in predicting long-term survival, but FIPS score has a relatively poor predictive ability in predicting both short-term and long-term survival.
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Hepatic sinusoidal obstruction syndrome (HSOS) is a vascular liver disease characterized by varying degrees of liver injury and portal hypertension. HSOS in China is mostly associated with the intake of pyrrolizidine alkaloids. The step-up approach with anticoagulant therapy and transjugular intrahepatic portosystemic shunt (TIPS) as the core treatment methods is the therapy currently recommended for this disease. Subcutaneous injection of low-molecular-weight heparin is the first choice for anticoagulant therapy, and oral warfarin can be used in combination or sequentially to enhance anticoagulation. Patients with no response to anticoagulant therapy can switch to TIPS. The Drum Tower Severity Score (DTSS) system can be used during treatment to evaluate the severity of the disease, in order to identify high-risk patients earlier and switch to TIPS in time, thereby improving the prognosis of patients.
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Gastroesophageal variceal bleeding is the life-threating complication of cirrhotic portal hypertension, and transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for portal hypertension-related complications. TIPS can be used for the prevention of first-time bleeding in patients with recurrent or intractable ascites. TIPS should be performed as early as possible for patients at a high risk of acute variceal bleeding (Child-Pugh class C 7 points with active bleeding on endoscopy or hepatic venous pressure > 20 mmHg). TIPS is an effective salvage therapy for acute variceal bleeding with failure after standard treatment, and is also a second-line option for preventing variceal rebleeding.
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Objective:To explore the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of esophago-gastric variceal bleeding (EGVB) complicated with cavernous transformation of portal vein (CTPV).Methods:From January 1, 2015 to December 31, 2018, the clinical data of liver cirrhosis patients with EGVB and complicated with (CTPV group) or without (non-CTPV group) CTPV receiving TIPS at Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School were retrospectively analyzed. The success rate of operation, stent patency rate, recurrent bleeding rate, incidence and survival rate of hepatic encephalopathy of CTPV group and non-CTPV group were analyzed. Independent samples t test, Mann-Whitney U test and chi-square test were used for statistical analysis. Kaplan-Meier method was used for survival analysis. Results:A total of 37 liver cirrhosis patients with EGVB and CTPV receiving TIPS treatment were screened out, among which 10 patients (27.0%) failed the portal vein puncture during the TIPS and switched to endoscopic treatment, the success rate was 73.0%. A total of 460 liver cirrhosis patients with EGVB and non-CTPV received TIPS treatment, among which TIPS in 18 patients (3.9%) was failed, and the success rate was 96.1%. With 1∶2 ratio propensity matching, 54 patients were enrolled in non-CTPV group. In the CTPV group, after TIPS treatment, the average portal vein pressure decreased from (28.9±5.1) mmHg (1 mmHg=0.133 kPa) to (18.8±4.5) mmHg, and the difference was statistically significant ( t=7.122, P<0.01). The median follow-up time was 33 months(1 to 66 months). There were no significant differences between the CTPV group and the non-CTPV group in one-year of cumulative stent patency rate (75.0% vs. 86.8%), recurrent upper gastrointestinal bleeding rate of hepatic encephalopathy (21.0% vs. 10.0%), the incidence of hepatic encephalopathy (34.8% vs. 22.2%) and the survival rate (80.7% vs. 88.9%)(all P >0.05). Conclusion:TIPS is safe and effective in the treatment of liver cirrhosis patients with EGVB and CTPV, and does not increase the incidence of postoperative complications and long-term mortality.
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Objective:To investigate the changes of liver volume and liver function in patients with extensive hepatic vein occluded Budd-Chiari syndrome (BCS) treated with transjugular intrahepatic portosystem shunt (TIPS).Methods:The clinical data of 29 BCS patients from Affiliated Hospital of Xuzhou Medical University during March 2016 to June 2019 were retrospectively collected and analyzed. The BCS was caused by extensive hepatic vein occlusion and patients were treated with TIPS. Pre- and postoperative abdominal CT/MRI images were collected and analyzed, and hepatic volume was measured with 3D-reconstruction. The liver volume and liver function during before and post the surgery were also collected and analyzed with preoperative value.Results:Patients including 8 males and 21 females, aged (33.3±6.3) years, were enrolled in this study. TIPS was successfully performed in all patients, with a technical success rate 100%. No serious complications related to TIPS occurred. Patients were followed up for 12-33 months (median, 16 months). Compared with preoperative [(2 124.6±420.9) cm 3] , the hepatic volume of time points after operation [1 week: (1 926.3±372.3) cm 3; 3 months: (1 480.6±183.1) cm 3; 6 months: (1 461.9±153.0) cm 3; 12 months: (1 469.3±148.5) cm 3] were all significantly reduced, and the differences were statistically significant ( P<0.05). Compared with preoperative values, the hepatic function indexes at each time point after operation were significantly improved ( P<0.05). The complete remission rate of ascites was 96.4% (27/28), 100.0% (28/28) and 100.0% (28/28) at 3, 6 and 12 months, respectively. Conclusion:The extensive hepatic vein occlusive BCS patients were benefit from TIPS therapy. Six months after operation, the hepatic volume and the hepatic function returned to normal level.
ABSTRACT
Sarcopenia is a common and insidious complication in patients with liver cirrhosis and is closely associated with the prognosis of patients with liver cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) is an important method for the treatment of portal hypertension-related complications. More and more studies have shown that sarcopenia is associated with the prognosis of cirrhotic portal hypertension after TIPS. This article reviews the research on sarcopenia and its association with TIPS in China and globally, in order to explore the association between them and guide clinical treatment.
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Esophageal and gastric variceal bleeding (EGVB) is a serious complication of portal hypertension, and it is necessary to control the progression of esophageal and gastric varices in clinical practice and prevent and treat EGVB; however, the mortality rate associated with variceal rupture and bleeding remains high at present. As for clinical treatment, risk classification of patients should be performed based on clinical and hemodynamic features and individualized treatment should be adopted, taking into account the balance of "embolization, shunt, and perfusion" of portal hypertension, so as to improve the clinical outcome and prognosis of patients with liver cirrhosis.
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Globally, the population living with liver cirrhosis is growing. There is the largest number of cirrhosis patients in China throughout the world. Acute-on-chronic liver failure (ACLF) is a clinical syndrome of sudden hepatic decompensations such as variceal bleeding, spontaneous bacterial peritonitis, hepatic encephalopathy and hepatorenal syndrome seen in patients with liver cirrhosis. ACLF leads to poor quality of life and high mortality. Portal hypertension is not only a consequence of the development of cirrhosis, but also a secondary or even superimposed attack to the development of cirrhosis. It is necessary to early reduce intrahepatic resistance by transjugular intrahepatic portosystemic shunt and drugs to improve the prognosis.
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Hepatic encephalopathy (HE) is a common complication after transjugular intrahepatic portosystemic shunt (TIPS), and there are still no systematic strategies for prevention and treatment at present. Based on recent studies in China and foreign countries, this article analyzes and summarizes the risk factors for HE after TIPS and the advances in treatment and prevention. It is pointed out that early diagnosis and prevention of covert HE should be emphasized in further research, and it is important to standardize the prevention strategies for HE after TIPS.
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ObjectiveTo investigate the changes in gut microbiota after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients with mild hepatic encephalopathy (MHE) in different prognosis groups. MethodsA total of 28 MHE cirrhotic patients who were hospitalized and underwent TIPS in Xijing Hospital of Digestive Diseases from July 2016 to July 2017 were enrolled. Fecal samples and related clinical data were collected on days 1-3 before surgery and at 1 month after surgery. According to the prognosis after surgery, the patients were divided into none-hepatic encephalopathy (HE) group with 8 patients, MHE group with 12 patients, and overt hepatic encephalopathy (OHE) group with 8 patients. Fecal samples were analyzed by 16S rRNA sequencing to obtain the relative abundance of gut microbiota, and SPSS and R packages were used to analyze the biodiversity, postoperative changes, and differences in such changes of gut microbiota at the genus level between groups. The chi-square test was used for comparison of categorical data between groups; the Kruskal-Wallis H test was used for comparison of continuous data between three groups; the Bonferroni method was used for multiple comparisons of multiple samples; the Wilcoxon signed-rank test was used for comparison before and after surgery within each group. For microbiome beta-diversity analyses, a principal coordinate analysis (PCoA) was performed based on Bray-Curtis distance matrix, and the Adonis method (PerMANOVA) was used for comparison between groups. ResultsPCoA based on Bray-Curtis distance matrix showed that only the MHE group had a significant change in beta diversity after surgery (F=2.71, P=0.049). After surgery, the non-HE group had significant increases in the abundance of the native flora Dialister, Coprococcus, Ruminococcaceae_uncultured, Flavonifractor, and Clostridium_sensu_stricto_1 (Z=2.521, 2.1, 2.1, 2.1, and 1.96, all P＜0.05); the MHE group had significant reductions in the abundance of the harmful flora Granulicatella（Z=2.521,P=0.012）, Enterococcus（Z=2.51,P=0.012）, Streptococcus（Z=2.432,P=0.015）, and Rothia（Z=2.001,P=0.045） and significant increases in the abundance of Veillonella（Z=2.353,P=0.019） and Megasphaera（Z=1.955,P=0.05）; the OHE group only had a significant increase in the abundance of Veillonella after surgery (Z=2.38, P=0.017). There was a significant difference in the change in gut microbiota (postoperative abundance/preoperative abundance) between the non-HE group, the MHE group, and the OHE group ［2.00 (1.11-91.61) vs 1.21 (0.26-679) vs 0.09 (0.01-0.92), χ2=6.249, P=0.043］. ConclusionThere is a significant difference in the change in gut microbiota after TIPS between patients with different prognoses, and the increase in the abundance of native flora may have a certain influence on the remission of MHE.
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Liver cirrhosis is the end stage of various chronic liver diseases, and portal hypertension is a main complication of liver cirrhosis. In this pathological state, spontaneous portosystemic shunt (SPSS), as the collateral circulation of the portal venous system, has not attracted enough attention in terms of occurrence mechanism and clinical value. The analysis shows that although SPSS is a natural shunt channel, further studies are still needed to clarify whether it can be used as a decompression method for portal hypertension, and a deeper understanding of SPSS will provide important guiding significance for the diagnosis and treatment of portal hypertension.
ABSTRACT
Liver cirrhosis is the end stage of various chronic liver diseases, and portal hypertension is a main complication of liver cirrhosis. In this pathological state, spontaneous portosystemic shunt (SPSS), as the collateral circulation of the portal venous system, has not attracted enough attention in terms of occurrence mechanism and clinical value. The analysis shows that although SPSS is a natural shunt channel, further studies are still needed to clarify whether it can be used as a decompression method for portal hypertension, and a deeper understanding of SPSS will provide important guiding significance for the diagnosis and treatment of portal hypertension.
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Chylous Ascites (CA) and chylothorax (CTx) are associated with obstruction, disruption or insufficiency of the lymphatic system. We report a 68-year-old male, with a history of alcoholic cirrhosis, who had recurrent events of CTx and CA. After a complete study, no other etiologies other than portal hypertension were found. Therapy with diuretics, nothing per mouth, parenteral feeding plus octreotide did not relieve symptoms. A transjugular intrahepatic portosystemic shunt (TIPS) was successfully placed and pleural effusion subsided. This case shows that CA and CTx can be caused by portal hypertension and they may subside employing a multimodal management strategy.